Provider Demographics
NPI:1417991530
Name:BUBEN, MICHAEL CHARLES
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHARLES
Last Name:BUBEN
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:CHARLES
Other - Last Name:BUBEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 269
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:WA
Mailing Address - Zip Code:98586-0269
Mailing Address - Country:US
Mailing Address - Phone:360-875-5579
Mailing Address - Fax:360-875-5235
Practice Address - Street 1:826 ALDER ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:WA
Practice Address - Zip Code:98586-4900
Practice Address - Country:US
Practice Address - Phone:360-875-5579
Practice Address - Fax:360-875-5235
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001152207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7093644Medicaid
WA1035732Medicaid
WA0049602OtherLABOR&INDUSTRY-BUBEN
WA7125362Medicaid
WA11143410OtherCAQH
WA503891Medicare Oscar/Certification
WAGAB11482Medicare PIN
WA0049602OtherLABOR&INDUSTRY-BUBEN
WA7093644Medicaid